Ártículo original Reasons for absenteeism in rural...

Rev. salud. bosque. | ISSN 2248-5759 (impresa) | ISSN 2322-9462 (digital)

| 1ene. - jun. de 2020 | Volumen 10 | Número 1 | Págs. 1-12

Ár t ículo or ig inal

Recibido: 30 | 01 | 2020

Aprobado: 25 | 02 | 2020

Publicado: 18 | 05 | 2020DOI: https://doi.org/10.18270/rsb.v10i1.3030

Reasons for absenteeism in rural primary schools in two Colombian municipalitiesRazones de ausentismo en escuelas primarias rurales de dos municipios colombianosRazões do não comparecimento nas escolas primarias rurais nos municípios colombianos

Abstract

Background: School absenteeism is a considerable problem generally related to higher dropout rates, poor academic achievement and school lag. This study determined the frequency and causes of overall and ill-ness-related absenteeism of students in rural schools from two Colom-bian municipalities.

Methods: A prospective and descriptive study was conducted in a popula-tion of 948 school children from 34 rural schools. Absenteeism data were collected for 2013 academic year consisted of the number of students re-gistered and absent by grade, school, day and reason for absence. Absen-ce rates (overall and illness-related absenteeism) were recorded, based on full or partial days absence, measured both as episodes, and accumulating the number of days.

Results: From the students included in the study, 55.1% were male and 71.6% were between 5 and 9 years old. The overall absence rate was 5.7 episodes per child-year (95% confidence interval 5.5 to 5.8) and 8.6 days per child-year (8.4 to 8.9). The main reasons for non-attendance were ill-ness (24.4%), medical or dental check-up (12.9%), travel (12.3%), lack of motivation to attend school (10.0%) and bad weather (9.3%). The illness-related absence rate was 1.4 episodes per child-year (95% confidence in-terval 1.3 to 1.5) and 2.5 days per child-year (2.4 to 2.6). The main reasons for illness-related absence were cold (37.0%), nonspecific fever (10.9%) and stomach pain or vomiting (8.4%).

Conclusions: In this study, the most common reasons for non-attendance were illness-related. The importance of respiratory and gastrointestinal in-fections in absenteeism was evident, showing rates similar to other urban school studies. Then, the results of this study provide knowledge on the magnitude and reasons for absenteeism in rural schoolchildren.

Keywords: School Absenteeism; Illness; Rural Health; Primary School; Students, Colombia.

How to cite:Vargas SL, Matiz MI, Olano VA, Sarmiento-Senior D, Jaramillo JF, Alexander N, et al. Reasons for absenteeism in rural primary schools in two Colombian municipalities. Rev. salud. bosque. 2020;10(1): Págs. 1-12. DOI: https://doi.org/10.1827 0/rsb.v10i1.3030

Sandra Lucía VargasiD orcid.org/0000-0002-4242-3488

Facultad de Medicina, Universidad El Bosque, Bogotá, Colombia

María Inés MatiziD orcid.org/0000-0003-0881-9515

Víctor Alberto OlanoiD orcid.org/0000-0003-4010-0973

Diana Sarmiento-SenioriD orcid.org/0000-0002-9959-3226

Juan Felipe JaramilloiD orcid.org/0000-0001-6417-8578

Instituto de Salud y Ambiente, Universidad El Bosque, Bogotá, Colombia

Neal AlexanderiD orcid.org/0000-0002-6707-7876

MRC Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, England

Audrey LenhartLiverpool School of Tropical Medicine, Liverpool, England

Thor Axel StenströmiD orcid.org/0000-0002-4160-7867

Retired SARChI Chair: Institute for Water and Wastewater Technology, Durban University of Technology, Durban, South Africa.

Hans J. OvergaardiD orcid.org/0000-0001-7604-3785

Faculty of Science and Technology, Norwegian University of Life Sciences, Ås, Norway

Corresponding author:[email protected]

Reasons for absenteeism in rural primary schools in two Colombian municipalitiesVargas SL, Matiz MI, Olano VA, et al.

2 | Págs. 1-12 | Número 1 | Volumen 10 | ene. - jun . de 2020 | ISSN 2248-5759 (impresa) | ISSN 2322-9462 (digital) | Rev. salud. bosque.

Resumen

Antecedentes. El ausentismo escolar es un problema importan-te relacionado con altas tasas de abandono escolar, bajo rendi-miento académico y rezago escolar. Este estudio determinó la frecuencia y las causas del ausentismo general y el ausentismo relacionado con la enfermedad en estudiantes de escuelas ru-rales de dos municipios de Colombia.

Métodos. Se realizó un estudio descriptivo en una población de 948 escolares de 34 escuelas rurales. Los datos de ausentis-mo recopilados para el año 2013 consistieron en el número de episodios y días de ausentismo por grado y motivo de ausencia general y por enfermedad. Se calcularon las tasas de ausentis-mo general y por enfermedad.

Resultados. El 55,1% de la población participante eran hom-bres y el 71,6% tenían entre 5 y 9 años. La tasa de ausentismo general fue 5,7 episodios por niño-año, IC 95% (5,5-5,8) y 8,6 días por niño-año, IC 95% (8,4-8,9). Las principales razones del ausentismo fueron enfermedades (24,4%), chequeo médi-co u odontológico (12,9%), viajes (12,3%), falta de motivación para asistir a la escuela (10,0%) y mal clima (9,3%). La tasa de ausentismo por enfermedad fue 1,4 episodios por niño-año IC 95% (1,3-1,5) y 2,5 días por niño-año IC 95% (2,4-2,6). Las principales razones del ausentismo por enfermedad fueron el resfriado común (37,0%), la fiebre inespecífica (10,9%) y el do-lor de estómago o vómito (8,4%).

Conclusiones. Las razones más comunes para la no asistencia estuvieron relacionadas con la enfermedad. La importancia de las infecciones respiratorias y gastrointestinales en el absen-tismo fue evidente, mostrando tasas similares a las de otros estudios en escuelas urbanas. Los resultados de este estudio proporcionan conocimiento sobre la magnitud y las razones del absentismo en la población escolar rural.

Palabras clave: Ausentismo Escolar; Enfermedad; Salud Rural; Escuela Primaria; Colombia.

Resumo

Antecedentes. O absentismo escolar é um grande problema re-lacionado às altas taxas de evasão escolar, baixo desempenho acadêmico e atraso escolar. Este estudo determinou a frequên-cia e causas do não comparecimento geral e por doenças em estudantes de escolas rurais de dois municípios da Colômbia.

Métodos. Estudo descritivo, realizado em uma população de 948 escolares de 34 escolas rurais. Os dados de absentismo coletados para 2013 consistiram no número de episódios e dias de não comparecimento por grau e motivo da ausência geral e por doença, foram calculadas as taxas de cada evento.

Resultados. 55,1% da população participante eram crianças masculinas do primeiro grau, 71,6% entre 5 e 9 anos de idade. A taxa geral de absentismo foi de 5,7 episódios por criança-ano, IC95% (5,5-5,8) e 8,6 dias por criança-ano, IC95% (8,4-8,9).

Os principais motivos do não comparecimento foram doenças (24,4%), check-up médico ou odontológico (12,9%), viagens (12,3%), falta de motivação para frequentar a escola (10,0%) e mau tempo (9,3%). A taxa de absentismo da doença foi de 1,4 episódios por IC95% criança-ano (1,3-1,5) e 2,5 dias por IC95% criança-ano (2,4-2,6). Os principais motivos da ausência de doença foram resfriado comum (37,0%), febre inespecífica (10,9%) e dor de estômago ou vômito (8,4%).

Conclusões. Os motivos mais comuns de não comparecimento foram relacionados à doença. A importância das infecções respi-ratórias e gastrointestinais no absenteísmo foi evidente, mostran-do taxas semelhantes às de outros estudos em escolas urbanas. Os resultados deste estudo fornecem informações sobre a magni-tude e as razões para evasão escolar na população escolar rural.

Palavras-chave: Absentismo Escolar; Doenças; Saúde Ru-ral; Escola Primária; Colômbia

IntroductionAcademic success depends largely on student atten-dance at school. Student absence strongly affects the results of standardized testing, graduation and dropout rates (1). Therefore, student absence is a concern of educational institutions and authorities. Despite many efforts to reduce absence, it remains a complex and challenging problem for the education system (2). Re-cently, the International Network for School Attendan-ce (INSA) was founded to promote school attendance, reduce absenteeism and solve school attendance pro-blems (3).

In the last 50 years, there have been several studies on school absence in North America and Europe, but few in developing countries. In the United States, there is controversy as to the main causes of school absen-teeism, and the importance of socioeconomic factors and educational quality (4). A rural study in India, re-ported adverse weather conditions, child labor and illness as the main reasons for absenteeism (5). A me-ta-analytic review revealed significant and substantial effects for school absenteeism related to physical and mental problems of the child, substance abuse, antiso-cial or risky behavior, problems at or with school (e.g., having a negative school attitude), characteristics of the school (e.g., low quality of the school or education sys-tem), parenting and family problems (6).

Schools are frequently affected by outbreaks of infec-tious, causing increased absenteeism of students and teachers, increased health spending, and decreased learning process among children (7,8). In 2012-2013,

| 3Rev. salud. bosque. | ISSN 2248-5759 (impresa) | ISSN 2322-9462 (digital) | ene. - jun. de 2020 | Volumen 10 | Número 1 | Págs. 1-12


approximately 19% of students from preschool to fifth grade in New York City were absent for at least 10% of the academic year (9), a level considered as chronic absenteeism. Similarly, schools in low-income neighbor-hoods reported chronic absenteeism rates up to 40% (9).

School absenteeism due to health problems is also an important concern of public health authorities. Lau et al (2012) attributed about 75% of all school absences to illness (10). In the United States, 3.5% of school-aged children missed 11 or more days of school in the last year because of illness or injury (11). Infectious diseases are a major reason for absenteeism in students in ele-mentary schools (8). A systematic review of pediatric influenza identified that the average length of absence from school or day care associated with confirmed in-fluenza ranged from 2.8 to 12 days for children (12). In Ohio (USA), a study reported that among the main causes of illness-related absence were gastrointestinal and respiratory infections (13).

Children often do not attend school due to minor ill-nesses like colds or minor pain. These children often return to the classroom without long-term consequen-ces for their education. However, children with chro-nic illnesses like asthma, migraine headaches, mental health conditions, and eczema/psoriasis/skin disorders have frequent absences due to medical appointments, therapies, or acute episodes of illness. Recurrent ab-senteeism due to these illnesses hinders academic pro-gress, increases dropout rates and affects professional career success in adulthood (14-16).

Absenteeism affects the self-esteem and academic performance of children. It affects not only educational attainment, but also interferes with screening programs and interventions by health institutions in schools (5). Moreover, it most often affects the population sectors that suffer marginalization or social or economic depri-vation, e.g. ethnic minorities and rural populations. Cu-rrently, various longitudinal studies revealed sustained or increasing rates of absenteeism (1,3,17,18).

Education is considered a fundamental right in Colom-bia. However, there are gaps in coverage and quality, affecting lower income households, specific regions, rural population and ethnic minorities. In 2015, there was a mean of 5.5 years of education in rural while in urban areas was 9.2 years (19,20).

In Colombia, there are just a few studies on school ab-senteeism, and most of them have been conducted in the urban area. These studies report absenteeism rates

around 1.0 day per child-year, with outstanding defini-tion and measurement period differences (21-27). Some of these studies identify family dysfunction and health problems such as asthma and rhinitis as variables that explain higher rates of absenteeism and poor academic performance (25-27). One of the difficulties in descri-bing this problem is the lack of reliable statistics at natio-nal and local level, particularly in rural areas.

Then, to gain a greater understanding of the frequen-cy and causes of overall illness-related school absen-teeism in rural schools, a study was conducted in the municipalities of Anapoima and La Mesa, two towns located in Cundinamarca, a province in the central re-gion of Colombia, as part of a larger project on school-based dengue and diarrhea control (28).

Methodology

Study areaThis study was conducted at 34 rural primary schools from Anapoima and La Mesa, two municipalities from the province of Cundinamarca, Colombia. All partici-pant schools were enrolled on the “Escuela Nueva Mo-del”, a multi-grade classroom.

The municipality of Anapoima has a population of 13,700 inhabitants and La Mesa 30,250 inhabitants, of which 58% and 42% live in rural areas, respectively (29,30). The main sources of income in the two muni-cipalities are agriculture (sugar cane, coffee and fruit), along with tourism (29,30).

All the schoolchildren registered on every rural school of both municipalities in 2013 were included. In Anapoima, 400 children, aged 4-15 years, participated in the study; and in La Mesa, 548 children aged 4-16 years participa-ted also. In 2010, the proportion of people with Unmet Basic Needs (UBN) in the rural areas of Anapoima and La Mesa were 36.4% and 36.8%, respectively (31,32). The UBN index is a direct method to identify critical shorta-ges in a population, mainly to characterize poverty; it is composed of indicators such as housing, sanitation, basic education, and minimum income. In 2013, the dropping out proportion of children in La Mesa was 5.4% and in Anapoima was 2.2 (33). In 2017, both municipalities had higher dropout rates in rural areas, as such: Anapoima 0.5% vs 2% and La Mesa 3% vs 3.6%. Compering with the national dropout rate levels they were 3.7% vs 4.2%, and with the Province of Cundinamarca 3.0% vs 2.9% (34). Data about absenteeism were not found.



Data collectionAbsences were recorded daily in a format that inclu-ded the child’s name, date of start and end of absence, reason for absence (illness, bad weather, travel, lack of motivation, other and unknown reason) and who gave the information. ‘Other’ reasons were noted and later categorized. If the reason for absence was illness it was noted whether the student consulted health services, what the diagnosis was (dengue, diarrhea, flu, other, unknown), and what kind of symptoms had (fever, diarr-hea, vomiting, headache, cough / runny nose, skin rash, others, unknown). This questionnaire was completed by schoolteachers during the 2013 school year (January 21 to November 22, covering 39 school weeks).

An absence episode was defined as the non-presence of the student throughout all, or part of a school day. For example, a child who got sick while at school and returned home before the end of the school day was re-corded as an absence episode. Overall absenteeism was defined as not attending school for any reason, inclu-ding illness. An absence episode due to illness was defi-ned as non-presence of the student due to any illness or symptoms. Absence for health reasons were established by phone calls to parents and, when parents could not be contacted by phone, house visits were conducted. A new absence episode was defined when at least three days passed without absence for the same reason from the last day of an episode to the new one. The length of an absence episode was specified as the number of days between and including the first and the last day of absence (excluding weekends and holidays). The term chronic absence was used when one student was absent more than 10% of the school year for any reason (1).

In cases where the absence was due to illness or the motive was unknown, a group of project assistants ca-lled the parents or guardians of the child to establish the reason. During this phone call questions were as-ked about the child’s symptoms, including gastrointes-tinal, respiratory or other symptoms, whether health services were consulted, and history of hospitalization.

A respiratory infection was defined as a subject having at least two of the following symptoms: (a) nasal discharge, (b) stuffy or blocked nose or noisy breathing, (c) cough, (d) feeling of chills or fever (e) throat pain, or (f) sneezing (35). Gastrointestinal infection was defined as one or both of the following: (a) passage of three or more loose or liquid stools (or more frequent passage than is normal for the individual) during a 24 hours’ time period or (b) any episodes of vomiting (35). Probable dengue cases were defined according to WHO criteria (36).

Data analysisThe total number of absence episodes, length in days, the proportion of absences attributable to each cause, rate of absence episodes and rate of absence days in each school were calculated. These rates were expres-sed per year based on a school year of 185 days and the confidence intervals were calculated performing a Poisson distribution.

Data were entered into Microsoft Excel version 2007 and analyzed in SPSS version 21.

Ethical considerationsThe project was presented to school principals and tea-chers who signed consent to participate on behalf of each school. The study was approved by the Comité Institu-cional de Ética en Investigaciones de la Universidad El Bosque, Bogotá, Colombia (Acta No. 146 of 30/08/2011) and the Ethical Review Board of London School of Hy-giene and Tropical Medicine (Ref. no. 6289). Written consent and acceptance were documented by most parents and involved students. Parental consent was sought via information and consent forms that students were asked to take home. Some forms were mislaid and, comparing the ones already returned, many were found to be illegible, or unidentifiable for other reasons such as names being incomplete or at high variance with tho-se in our records. However, oral consent from parents or guardians was sought as well during telephone calls when establishing reasons for student school absences. Bearing in mind that this study had a minimal risk in terms of the Colombian Ministry of Health, Resolution 8430 of 1993, a permission was sought and received from the ad-hoc ethical committee of the Universidad El Bosque (Acta No. 009 of 27/11/2014) and from the Ethics Committee of the London School of Hygiene and Tropical Medicine (reference 10453/6289, 7 March 2016) to publish all data collected.

ResultsA total of 948 school children and adolescents were included in the study. The characteristics of the study population are shown in Table 1. Data are lacking for 37 children in relation to age and 25 related to grade. The mean age was 7.9 years (range 12). From the total of students that entered the study at the beginning of the school year, 160 (16.9%) withdrew before comple-ting the school year and 184 (19.4%) were enrolled af-ter the school year started.



Table 1. Characteristics of students in 34 schools in rural areas of the municipalities of Anapoima and La Mesa, Cundinamarca, Co-lombia. 2013

Anapoiman (%)

La Mesan (%)

Totaln (%)

Age

<6 years 74 (18.5) 68 (13.3) 142 (15.6)

6-9 years 236 (59.0) 306 (59.9) 542 (59.5)

>9 years 90 (22.5) 137 (26.8) 227 (24.9)

Total 400 (100) 511 (100) 911 (100)

Sex

Male 218 (54.5) 304 (55.5) 522 (55.1)

Female 182 (45.5) 244 (44.5) 426 (44.9)

Total 400 (100) 548 (100) 948 (100)

Grade Level

Preschool 64 (16.0) 72 (13.8) 136 (14.7)

First 76 (19.0) 106 (20.3) 182 (19.7)

Second 65 (16.3) 93 (17.8) 158 (17.1)

Third 73 (18.3) 80 (15.3) 153 (16.6)

Fourth 59 (14.8) 98 (18.7) 157 (17.0)

Fifth 63 (15.8) 74 (14.1) 137 (14.8)

Total 400 (100) 523 (100) 923 (100)

Source: Own elaboration.

Overall absenteeismThe total number of absence episodes was 4241. Of these 2377 (56.0%) were in La Mesa and 1864 (44.0%) in Anapoima. A total of 6481 absence days were recorded, 3837 (59.2%) in La Mesa and 2644 (40.8%) in Anapoima. A large proportion (81.1%) of children were absent one or more days during the school year; all the children in two schools in Ana-poima and one in La Mesa did not attend at least once a year. Three quarters of the absences lasted for one day.

There was an average of 5.7 absence episodes per child-year (CI95% 5.5-5.8) and 8.6 absence days per child-year (CI95% 8.4-8.9) (Table 2). There were no substantial differences between the two municipali-ties related to the mean number of absence episodes (Anapoima: 6.5 episodes/student/year; La Mesa: 5.5 episodes/student/year) and number of days (Anapoi-ma: 9.0 days/student/year; La Mesa: 9.5 days/student/year). Chronic absenteeism occurred in 64 (6.8%) students who were from 20 out of the 34 analyzed schools (58.8%).

Table 2. Number and rates (per child-year; 95% confidence inter-val) and days of absence episodes from 34 schools in rural areas at the municipalities of Anapoima and La Mesa, Cundinamarca, Co-lombia. 2013.

Type of absence

Absence episodes Absence days

n Rate 95% CI n Rate 95%

CI

Overall absencea 4 241 5.66 5.48-5.83 6 481 8.64 8.43-

8.85

Illness-related absenceb 1 025 1.40 1.28-

1.45 1 864 2.49 2.37-2.60

Respiratory infections 264 0.35 0.31-

0.39 380 0.51 0.46-0.56

Gastrointestinal infections 184 0.25 0.21-

0.28 264 0.35 0.31-0.39

Fever 111 0.15 0.12-0.18 191 0.26 0.22-

0.29

a Overall absence includes illness-related absence, respiratory infections and gastrointestinal infections.

b Illness-related absence includes respiratory infections, gastrointestinal infections and fever.


Overall absenteeism and illness rates were hig-hest among children under 6 years of age and fe-males. Regarding grades, the highest rates of ab-senteeism were the preschool and the first-grade groups (Table 3).



Illnes

Medical / dental Check-up

Travel (pou of study area)

Lack of motivation

Adverse weather conditions

Family dysfunction

Family commitments

Sick mother

Taking care of home or siblings

Other*

0,0 5,0 10,0 15,0 20,0 25,0 30,0

Table 3. Number and rates (per child-year) of absence episodes and days by sex, age and school grade in 34 schools belong to rural areas at the municipalities of Anapoima and La Mesa, Cundinamarca, Colombia. 2013.

Feature

Days of observation Overall absence Absence due to illness

Episodes Days Episodes Days

n Rate n Rate n Rate n Rate

Age (years)

<6 20 012 850 7.9 1 367 12.6 228 2.1 439 4.1

6-9 years 80 952 2 305 5.3 3 451 7.9 571 1.3 997 2.3

>9 years 34 490 1 003 5.4 1 511 8.1 213 1.1 406 2.2

SexMale 75 700 2 211 5.4 3 429 8.4 526 1.3 999 2.4

Female 63 045 2 012 5.9 3 025 8.9 499 1.5 865 2.5

School grade

Preschool 18 685 828 8.2 1 346 13.3 219 2.2 427 4.2

First 27 304 1 107 7.5 1 605 10.9 238 1.6 414 2.8

Second 22 775 599 4.9 916 7.4 145 1.2 267 2.2

Third 22 293 495 4.1 795 6.6 148 1.2 280 2.3

Fourth 23 013 583 4.7 852 6.8 116 0.9 205 1.6

Fifth 22 199 554 4.6 832 6.9 154 1.3 266 2.2


Absenteeism reasonsThe main reasons for absenteeism were general illness, medical or dental check-up, travel to the urban area of the municipality or another city, lack of motivation to

*Moreover, other reasons included were distance to school, lack of money for transportation, lack of escort to go with the child to the school, bereavement or other family misfortune, overslept, stayed at grandparents, moved to another house, religious festivities, unknown of scheduled classes, adaptation to school issues (for very small children).


go to school and adverse weather conditions, making travel to school very difficult. The study design did not distinguish whether medical and dental check-ups we-re made for sick or healthy children. The main reasons for absenteeism are shown in Figure 1.

Figure 1. Percentage of the reason of overall absence episodes in students from 34 rural schools.



Absenteeism due to illnessThe total number of absence episodes due to illness was 1025 distributed almost equally between municipalities (La Mesa: 1.1 episodes, 2.4 days/student/year and Ana-poima: 1.8 episodes, 3.0 days/student/year). The total number of absence days was 1864 (Table 2). Almost half (49.1%) of the students were absent due to illness for one or more days during the school year and 67.5 % of the episodes lasted one day. The range of duration of illness-related absence episodes was 1 to 33 days.

Table 4. Absenteeism due to illness in students from 34 schools in rural areas at the municipalities of Anapoima and La Mesa, Cundina-marca, Colombia. 2013

Symptom / IllnessAbsence episodes Absence days

n % n %

Common cold 378 37.0 627 33.7

Nonspecific fever 111 10.9 191 10.3

Stomach pain / vomiting 86 8.4 126 6.8

Diarrhea 81 7.9 118 6.3

Injuries 69 6.8 139 7.5

Headache 56 5.5 67 3.6

Tonsillitis 41 4.0 90 4.8

Dental problems 34 3.3 45 2.4

Ear infection / ear pain 23 2.3 36 1.9

Dengue 20 2.0 80 4.3

Asthma 19 1.9 37 2.0

Indigestion 19 1.9 28 1.5

Chicken pox 13 1.3 77 4.1

Skin problems 10 1.0 19 1.0

Other* 62 6.1 182 9.8

Total 1022 100 1862 100

*Other reasons with low frequencies were musculoskeletal pain, eye problems such as conjunctivitis, and surgery.


The illnesses that caused the longest absence episodes were chicken pox (average 5.9 days), dengue (average 4.0 days), and pharyngitis (average 2.2 days).

Fever was reported in 541 episodes, associated with 1,031 absence days. The distribution of illness episodes reporting fever were cold 53%, nonspecific fever 20.3%, pharyngitis 6.5%, diarrhea 6.3% and dengue 3.5%.

The largest number of illness episodes occurred in Au-gust. Common cold and dengue were most common

The highest rates of illness-related absenteeism were due to respiratory infections, gastrointestinal infections and fever of unknown origin (Table 2).

The main reasons for absenteeism from respiratory in-fectious were common cold, tonsillitis, ear pain, ear infections and asthma. Due to gastrointestinal infec-tions, the main reasons were stomach pain, vomiting, diarrhea and indigestion. Also, other important reasons for absenteeism due to illness were injuries, headache, dental problems and dengue (Table 4).

in June, but diarrhea, stomach pain and vomiting had a greater number of episodes in October.

Ten students (1.1%) were absent from school for ten or more days due to illness. These children were ab-sent from 1-10 times in the school year. One student was absent once for 33 days because of surgery. Some students had a longer episode of school absence, for example hepatitis (16 days), dengue (13 days), measles (12 days), chicken pox (12 days), flu (11 days), injuries (10 days), asthma (9 days) and trauma (7 days).



The total number of kids with absences related to asth-ma was 18 (1.9%). Students reporting asthma-related absence were absent from school three times more, compared to those with other illnesses, with 3.7 vs. 1.3 episodes per student/year and 7.8 vs. 2.4 days per student/year, respectively.

DiscussionSchool absenteeism was carried out in students aged 4-16 years throughout the 2013 school year at 34 rural schools in two municipalities from Colombia. The most common reasons for absence were illness (24.4%), me-dical or dental check-ups (12.9%), traveling (12.3%), lack of motivation to go to school (10.0%), and bad weather (9.3%). In Latin America, school absenteeism is generally related to poverty, for example inability to cover school expenses and transport to the school, particularly in rural areas (3,37). In this study these reasons only correspon-ded to 2.1%. Previous data from Colombia suggested that the main reasons for school absence were lack of resou-rces, the need to work, lack of interest in school, and ad-verse conditions, hindering access to rural schools (38).

Some studies show that other reasons for absence in school are health problems, malnutrition and child la-bor (37). A recent study conducted in these municipali-ties found an association between higher rates of school absenteeism and stunting or low height by age (39). The lack of interest of the parents of the children for educa-tion, the lack of support and attention by the teachers and insufficient attendance supervision and performan-ce of the students were also reported reasons for school absence (37). Some of these motives were among the main reasons for school absenteeism found in our study, e.g. the lack of motivation to go to school was 10.0%.

The limited gains in academic performance of schools in rural areas have been the subject of several studies and the conclusions were, in general, that these diffi-culties resulted from the socioeconomic conditions as well as the nature of the educational system in rural areas. In these mentioned areas, there is a pedagogi-cal-didactic structure based on heterogeneity and a multilevel group of different ages tangle with organiza-tional and administrative singular structure (3,40-44). Huge aspects that should be pointed out in these two municipalities, considering that lack of motivation was the fourth most common cause of school absenteeism, bad weather hampering access was the fifth, and children’s work and domestic tasks were among the ten main reasons. These causes of absenteeism reflect

the disadvantages of children and adolescents in ru-ral areas, since 70% of parents or caregivers in these municipalities have not completed primary education, in addition to having poor schools infrastructure; as it has also been reported in similar studies in the United States, Latin America and Colombia (9,45-47).

Illness was the leading cause of school absenteeism. In this study, the students lost an average of 2.5 days per academic year due to sickness. However, the magnitude of absence due to illness could be underestimated be-cause absences due to a medical or dental appointment did not distinguish between illness and routine checkups.

Absenteeism from infections is one of the major pro-blems in public and private schools (48). In the current study, respiratory and gastrointestinal infections were the most common reasons for illness-related absence, similar to those reported in other studies (49,50). The impact of respiratory and gastrointestinal infections on illness-related absenteeism was evident, causing about a third of the lost days.

The incidence of major infectious diseases such as dengue and influenza are higher in primary than in se-condary schools (51,52). Although dengue is endemic in the study area, and 2013 was an epidemic year (53), absence due to dengue was only 2%; even so, nons-pecific fever was the second reason for illness-related absence, and some of such episodes could have been related to dengue. Health services were consulted in only 27.5% of the illness absences. The use of absence data could be a useful strategy for surveillance and out-break detection (54), taking into account the barriers to access health services in rural areas (55).

Risk of gastrointestinal infections is heightened in Co-lombia by poor access to clean water, sanitation and hygiene, since only 54% of rural public schools have access to potable water, 57% to sewerage, and only 40% have enough bathrooms (56). Intestinal parasites and other pathogens could be an important health is-sue for research in these two municipalities because of diarrhea, vomiting and stomach pain were the third and fourth most common causes of illness-related ab-senteeism. In Peru, high morbidity due to parasitic in-fections had a direct effect on school absenteeism (57).

The main causes of chronic absenteeism due to illness in the current study was similar to other studies in the US and other countries (15,27). Children with special needs, for example asthma, can have rates of absenteeism up



50% higher than average, contributing to poor acade-mic achievement and higher dropout rates (14,26).

Chronic dental problems can also affect school atten-dance (58). In our study, only 3.3% of absences were due to dental problems, much less than the 22.5% re-ported in a study in Thailand (59). However, this issue might be underreported in our study, because when students went for a dental appointment it was not clear whether they went for a dental check-up or illness. More research is required to explore the relationship between absenteeism for dental reasons and severity of the den-tal conditions. Furthermore, in Colombia, other studies have shown that children in rural areas have worse oral health indicators than children in urban areas, sugges-ting greater inequity and poor access to health care (60).

As mentioned in the Mission for Transformation of the Country Report, Colombia has a historic debt with the rural area (61). The first point of The Havana Peace Agre-ement suggests a Comprehensive Rural Development. In education, it proposes to design a Rural Education Special Plan that makes possible for young people to stay in the country areas while doing productive task, allowing also the educational institutes to make impor-tant contributions in rural development (61). Thus, edu-cational institutes in rural areas of Colombia shows the big challenges for the post-conflict era, becoming a vital factor to close the huge urban-rural gap.

Absenteeism and dropping out of the school become a multifactorial issue, being the social, economic, family and school the most important, which make it difficult to cover from an exclusive school factor. Moreover, characteristics of rural areas such as lower number of students by grade, long distances between settlements or child labor during harvest seasons are complex pro-blems and require creative solutions. Other important factor is the fact that rural education rarely establish links with productive projects and does not develop work programs along with an effective articulation with technical and technological education (61).

School absenteeism is an initial symptom before drop-ping out happens. Therefore, it is important to monitor assistance dynamics to intervene early. Absenteeism can raise prejudice over students affected, their fami-lies and, in general, society, limiting rights to a com-prehensive development of children and adolescents.

In conclusion, this study contributes to knowledge about school absence — overall and due to illness— in schoolchildren of Colombian s rural areas. In this

country, few previous studies of absenteeism empha-sized dropout rates and did not evaluate absenteeism as dropping out signal. It is also important to consider the impact of infectious diseases on school attendan-ce, considering the conditions in rural areas in terms of access to health services, limitations of school health surveillance systems, and poor water, sanitation and hygiene, among others.

In addition, the need of improving systems to record school absenteeism could be a useful tool for stren-gthening illness surveillance systems in these areas. It is important to know the health-related causes of school absenteeism and establish whether there is a relations-hip with the frequency of illness at the community level. The formulation of effective policies and action plans to reduce absenteeism requires the collaboration among health professionals, local authorities and the education community to reach intervention on social determinants and control of the main causes. Then, the results of this study encourage existing intersectoral collaborations to strengthen and establish new multidisciplinary partner-ships to learn in depth about the relationship between student absenteeism and school permanence.

One limitation of this study was that illness diagnosis is based on symptoms reported by parents or guardians without microbiological confirmation and details of health care professionals. The comparison of our data with other studies is limited by large variation in eva-luating school absenteeism methodology, since there is no standardized tool that can be applied worldwide.

Conflict of interestThe authors report no conflicts of interest.

FundingThis project was funded by the Research Council of Norway as part of HEALTHPLATFORM study (Grant ref. No 201349), the Lazos de Calandaima Foundation, and the Universidad El Bosque.

AcknowledgementsWe thank the mayors, health departments and staff education and rural schools in these municipalities for their cooperation during this project, as well as the following field workers: Humberto Mosquera, Nancy Herrera, Rosa Silva, Laura Cabezas, Paola Moreno, Sandra Moreno, Esmeralda González, Rosa Pulido and Luz Marina Contreras.



DisclaimerThe findings and conclusions in this report are those of the authors and do not necessarily represent the offi-cial position of any sponsoring entities.

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